Radical retropubic prostatectomy: bladder neck preservation versus reconstruction

Urinary Incontinence in Men

BACKGROUND

Despite similar rates of voiding dysfunction in older men and women, most funded research has focused on women. Strategic treatment plans for managing urinary incontinence and other lower urinary tract symptoms in men are limited by sparse or absent direct clinical evidence with most interventions supported by data extrapolated from studies in women.

OBJECTIVES

To explore what is known about the epidemiology and etiology of incontinence in men, highlight some of the gaps in the current knowledge, address limitations in existing research, and consider future directions in men's continence care.

METHODS

Existing literature on urinary incontinence in men was analyzed to generate a plan for future research.

RESULTS

Gaps in our knowledge of urinary incontinence in men remain in the areas of etiology, psychosocial consequences, and treatment efficacy.

CONCLUSIONS

Clinical research addressing incontinence in men is critical to explore the barriers or facilitators to seeking care, elucidate the biomechanical aspects of pelvic floor function, provide a clear description of the natural history of bladder dysfunction, and highlight the quality of life impact from incontinence.

Safety and outcome of early catheter removal after radical retropubic prostatectomy

OBJECTIVES

To assess the outcomes of patients who underwent radical retropubic prostatectomy (RRP) and had their indwelling urinary catheter removed on postoperative day 4 or later.

METHODS

The medical records of 342 consecutive patients undergoing RRP by a single surgeon were retrospectively reviewed. None of these patients had received radiotherapy, transurethral resection, or simple prostatectomy before RRP. The 342 patients were categorized into two groups according to the length of catheterization. Group 1 (n = 127) had the urethral catheter removed on postoperative day 4, and group 2 (n = 215) had the catheter removed later than postoperative day 4. Removal of the urinary catheter was only done if control cystography failed to demonstrate anastomotic extravasation. In the case of acute urinary retention, home care nurses and emergency room personnel reinserted the urinary catheter without cystoscopic assistance. Incontinence was rated according to the number of protective pads used in a 24-hour period as follow: none, mild (1 pad/day), moderate (more than 1 but 3 or fewer pads/day), and severe (more than 3 pads/day).

RESULTS

The mean age of the study population was 61.5 +/- 6.1 years. Acute urinary retention after catheter removal occurred in 11 patients (3%), 4 from group 1 and 7 from group 2. None of the patients requiring catheter reinsertion presented with complications related to this event. The overall continence rate was 58%, 85%, and 92% at 3, 9, and 12 months, respectively. The continence rates at 3, 9, and 12 months were higher for group 1 than for group 2 (P = 0.0002, P = 0.011, and P = 0.044, respectively). Bladder neck contracture was encountered in 14 patients (4%), 2 (2%) from group 1 and 12 (6%) from group 2. The only factor predicting continence was the duration of bladder catheterization.

CONCLUSIONS

Bladder catheters can be safely removed on postoperative day 4 in patients with normal cystograms after RRP. The continence and anastomotic stricture rates were improved in patients with 4 days of indwelling catheterization.

Prostate cancer management: (1) an update on localised disease

Prostate cancer is receiving ever more publicity with the result that more men are having their prostate specific antigen checked and a greater proportion of men are diagnosed with potentially curable localised disease. Advances in the therapeutic modalities including radical surgery, external beam radiotherapy, and brachytherapy have reduced the incidence of side effects and now offer patients a choice of treatments depending on their tumour characteristics, age, and co-morbidity. A significant proportion of men do not need intervention and may be safely kept under a "watch and wait" policy. The use of genetic markers may in the future distinguish between patients most likely to benefit from radical therapy and those in who either palliation or observation is more appropriate. This review examines the potentially curative options, as well as expectant management, outlining the pros and cons of each. The use of adjuvant and neoadjuvant therapy is also discussed.

A low incidence of positive surgical margins in prostate cancer at high risk of extracapsular extension after a modified anterograde radical prostatectomy

OBJECTIVES

To evaluate the incidence of positive surgical margins (and associated risk factors) in patients with localized prostate cancer at high preoperative risk of extracapsular disease treated using a modified anterograde radical retropubic prostatectomy technique. Positive surgical margins are an important risk factor for disease recurrence after radical prostatectomy, particularly in patients with extracapsular disease.

PATIENTS AND METHODS

In total, 84 patients with clinically localized prostate cancer and a preoperative prostate-specific antigen (PSA) level > 10 ng/mL and/or a biopsy Gleason score > or = 7 were evaluated. The surgical technique allows easy, wide resection of the posterolateral prostatic pedicles, and good mobilization and exposure of the apex before the urethra transection. Prostatectomy specimens were examined for extracapsular tumour spread and positive surgical margins. Differences in putative risk factors (Gleason score, preoperative PSA level, prostate weight) between the positive- and negative-margin groups were evaluated using the Mann-Whitney test.

RESULTS

Overall, 11 of the 84 (13%) patients had positive surgical margins and of these a single site was involved in six. In total, 15 positive-margin sites were identified (five apical, four basal, three posterolateral, two anterior and one posterior). All patients with positive margins had histological extracapsular disease. The preoperative PSA level and Gleason score were significantly higher in the positive- than in the negative-margin group (P = 0.025 and 0.035, respectively).

CONCLUSIONS

The anterograde radical prostatectomy minimizes the incidence of positive surgical margins in patients at high risk of extracapsular disease.

Urinary incontinence after radical retropubic prostatectomy: the outcome of a surgical technique

OBJECTIVE

To analyse the incidence of incontinence after radical retropubic prostatectomy (RRP) and the time to return of continence, using an RRP technique including a novel posterior bladder plication

PATIENTS AND METHODS

We retrospectively reviewed the medical records of 200 consecutive patients who underwent RRP between September 1995 and February 1997, by one surgeon, at our institution. Patient characteristics including age, preoperative prostate-specific antigen (PSA) level and Gleason grade, were assessed. Continence was assessed before and after RRP by either a third-party patient interview or a prospective validated questionnaire. Continence was defined as not requiring the use of any sanitary pads or diapers. The continence rate was determined immediately after catheter removal, and at 3, 6, 12 and 15 months after RRP.

RESULTS

The mean age of the patients was 59.4 years, the preoperative PSA level 8.5 ng/mL and the Gleason grade 6.1. The time to continence and percentage of continent patients was 63.5% immediately, 82% at 3 months, 91% at 6 months, and 98.5% at 12 months after RRP. At 15 months, 199 of 200 consecutive patients were continent (99.5%).

CONCLUSION

With our technique there was an early return to continence and only a minor incontinence rate at 15 months. The cumulative effect of sequential technical manoeuvres in our RRP technique, including posterior bladder plication, is critical for continence after RRP.

Technical advances in radical retropubic prostatectomy techniques for avoiding complications. Part II: vesico-urethral anastomosis and nerve-sparing prostatectomy

We previously reviewed different technical modifications and improvements in apical dissection in radical retropubic prostatectomy which have a considerable effect in optimizing the results. This second paper focuses on the vesico-urethral anastomosis and aspects of nerve-sparing prostatectomy.

Positive surgical margins in laparoscopic radical prostatectomy: the impact of apical dissection, bladder neck remodeling and nerve preservation

PURPOSE

We assess the incidence and location of positive surgical margins in a consecutive series of patients who underwent laparoscopic radical prostatectomy.

MATERIALS AND METHODS

Between May 1998 and September 2001, 235 men underwent laparoscopic radical prostatectomy at our institution. During this period modifications were made in the technique. We stopped preserving the puboprostatic ligaments during 1999 and stopped preserving the bladder neck during 2000. We compared the incidence of apical and bladder neck margins before and after these changes in surgical technique. Nerve sparing status was documented by the surgeon at the end of the operation and its effect on the incidence of lateral positive margins was evaluated. To concentrate on the surgically induced margins this study focused on pT2 cases.

RESULTS

There were 169 pT2 cases and 32 (18.9%) positive margin locations. A constant decrease was noted in the overall incidence of positive margins but, while apical margins were the most abundant in 1998, posterolateral margins were most abundant in 2001. Avoiding bladder neck preservation eliminated positive bladder neck margins in 2001. The overall incidence of positive lateral surgical margins in pT2 cases treated with a nerve sparing procedure was 8.4%.

CONCLUSIONS

The experience gained in this procedure led to a decrease in the incidence of positive margins. Wide resection of the bladder neck and cutting the puboprostatic ligaments decreased bladder neck and apical positive margins. Nerve preservation did not increase the incidence of positive margins. These technical modifications may improve the outcome of laparoscopic radical prostatectomy.

Avoidance and management of positive surgical margins before, during and after radical prostatectomy

Positive surgical margins after radical prostatectomy lead to an increased risk of progression and reduced disease free survival. Earlier detection of prostate cancer, appropriate patient selection and improved operative techniques can reduce the incidence of positive margins, though the risk can not be eliminated as pre-operative staging techniques are not sufficiently sensitive. Nerve sparing and bladder neck sparing do not adversely affect margin status in appropriately selected men. Once positive margins have been diagnosed the optimal management and the timing of treatment remains controversial. Adjuvant radiotherapy or salvage radiotherapy in men with a low PSA may improve local control and PSA free survival in some individuals, a survival benefit has not yet been established.

Outcomes after radical retropubic prostatectomy

OBJECTIVES

To determine whether urinary incontinence after radical retropubic prostatectomy (RRP) for prostate cancer is improved by the preservation of the puboprostatic ligaments or bladder neck; whether impotency is reduced by the preservation of the neurovascular bundles; and whether positive surgical margins are a risk with more precise bladder neck and apical dissection.

METHODS

RRP was performed sequentially in three groups using tennis racquet reconstruction, bladder neck preservation, or bladder neck and puboprostatic ligament preservation, and continence and surgical margin status were assessed. Also, recovery of potency and surgical margin status were evaluated when both, one, or no neurovascular bundles were preserved.

RESULTS

A total of 244 patients had a social continence rate of 90%, 100%, and 89% after tennis racquet reconstruction, bladder neck preservation, or bladder neck and puboprostatic ligament preservation, respectively. The mean time to recovery of continence was similar for tennis racquet reconstruction (2.3 months) and bladder neck preservation (2.9 months) but was longer (P <0.05) for bladder neck and puboprostatic ligament preservation (4.3 months). Although 9% of cases had positive margins, no margins were positive only at the bladder neck. Of a total of 188 patients potent preoperatively, 72% underwent bilateral nerve-sparing surgery. All men younger than 50 years old, 87% of men aged 50 to 59 years, 70% of men aged 60 to 69 years, and 38% of men older than 70 years of age were potent. The surgical margins were positive in 9% of patients who underwent bilateral nerve-sparing surgery, and the site of margin positivity was the apex only in 3% of patients.

CONCLUSIONS

Neurovascular bundle and bladder neck preservation decrease morbidity and rarely risk margin positivity. Bladder neck plus puboprostatic ligament preservation delays and does not improve overall continence.

Radical prostatectomy: bladder neck preservation and puboprostatic ligament sparing--effects on continence and positive margins

OBJECTIVES

To determine the effect of puboprostatic ligament sparing and bladder neck preservation on postoperative continence and positive margins after radical retropubic prostatectomy.

METHODS

A total of 149 men with clinically localized prostate cancer underwent radical retropubic prostatectomy. A bladder neck preservation technique was used in 48 patients (group 1), puboprostatic ligament sparing in 51 patients (group 2), and both techniques in 50 men (group 3). Urinary continence and margin status were assessed.

RESULTS

A statistically significant difference in the early return of continence was found 3 and 6 months postoperatively between groups 1 and 2 (P < 0.05), as well as between groups 2 and 3 (P < 0.05), in favor of groups 1 and 3. However, the long-term continence rates recorded 1 year postoperatively did not differ, at 92%, 92%, and 94% for groups 1, 2, and 3, respectively. Positive margins were found in 10 patients (21%) from group 1, in 9 (18%) from group 2, and in 11 (22%) from group 3. Positive margins at the bladder neck were found in 3 (6%), 1 (2%), and 2 (4%) patients, respectively, in groups 1, 2, and 3. These were the sole sites found in 1 patient (2%) in each of groups 1 and 3 and in none of group 2 (0%). Positive margins on the prostatic apex were found in 3 patients (6%) in group 1, 2 patients (4%) in group 2, and 4 patients (8%) in group 3. The apex was the only site found in 0 (0%), 1 (2%), and 2 (4%) patients for groups 1, 2, and 3, respectively. No statistically significant difference was found in the margin status among the groups studied.

CONCLUSIONS

The final continence rates did not differ among the three groups. However, bladder neck preservation offered an earlier return of continence compared with the puboprostatic ligament-sparing technique. The positive margin status was similar for all three groups.

Urinary incontinence following treatment of localized prostate cancer

BACKGROUND

Urinary incontinence (UI) following treatment for localized prostate cancer is a significant adverse consequence most commonly seen after radical prostatectomy. UI can significantly impair the quality of life of patients who can otherwise expect a long survival.

METHODS

The authors review past and present literature on UI following treatment for localized prostate cancer. Special focus is placed on the rate of UI following different modes of therapy, the effect of posttreatment UI on patients' quality of life, and the success of different methods used to treat the incontinence.

RESULTS

Postprostatectomy UI has been reported in 25%-70% of cases, but few patients report being significantly bothered by the symptom. Postradiation adverse effects are mainly acute inflammatory, while late complications are rare but usually more serious. Comparative studies estimate UI following prostatectomy to be two times more common than following radiation, and surgical patients are three times more likely to continue to use pads. Watchful waiting carries a risk of incontinence related to prostate tumor progression. Several interventions can improve UI.

CONCLUSIONS

UI is the most common adverse consequence from treatment for localized prostate cancer. All of the possible treatment modalities carry some risk of UI. Providing accurate information to patients allows them to make informed decisions regarding treatment and can improve the quality of life in the posttreatment period.

Intraoperative, perioperative, and long-term complications of radical prostatectomy

With improved surgical technique and perioperative care, the intraoperative and early postoperative complications of radical prostatectomy have decreased over the last 2 decades. Incontinence and impotence are two of the most significant long-term complications related to this procedure. Although the wide range of incontinence and impotence rates reported has been attributed to multiple factors, including the method of data collection and patient selection, it is apparent that the surgeon's experience is a significant factor, and that lower long-term morbidity can be expected from centers with more experience with radical prostatectomies. The impact of long-term complications, including urinary and sexual dysfunction, on the quality of life may be less than previously reported and should be discussed with patients.

Physiologic studies of male sexual dysfunction in multiple sclerosis

OBJECTIVE

We conducted this investigation to better define the neural disruptions that result in sexual dysfunction in men with multiple sclerosis (MS), using genital electrodiagnostic testing and nocturnal penile tumescence and rigidity monitoring.

METHODS

Thirteen men with MS and sexual dysfunction were recruited for the study. Twelve healthy, sexually potent men were enrolled as controls. All underwent pudendal somatosensory evoked potential (SEP) testing using standard methods, and a new modification to isolate the right and left dorsal nerves of the penis. RigiScan testing was performed on the MS subjects to assess nocturnal erectile function.

RESULTS

Unilateral and bilateral DNP SEPs were able to be performed on the control subjects. In all but one MS subjects, DNP SEP abnormalities were found. Three men had normal latency bilateral DNP SEP latencies, but on unilateral DNP testing, abnormalities were identified. Seven men, including those with abnormal or absent SEP latencies, had normal nocturnal erectile activity. There was no correlation between overall functional status, presence of abnormal or absent SEP, and quality of nocturnal erectile activity.

CONCLUSIONS

Genital SEP abnormalties are common in men with MS and sexual dysfunction. Unilateral DNP SEP testing was more sensitive in identifying abnormalities than the standard method of pudendal SEP testing. One of the causes of sexual dysfunction in men with MS may be due to genital somatosensory pathway disruption, with sparing of the efferent tracts in some men.

Does urethral-sparing prostatectomy risk residual prostate cancer?

OBJECTIVES

Urethral length after radical prostatectomy has correlated positively with postoperative urinary continence. Because sparing the prostatic urethra may improve continence after prostatectomy, we evaluated anatomic and pathologic consequences of urethral-sparing surgery.

METHODS

From February to October 1999, 12 patients with clinically localized prostate cancer received a bladder neck-sparing radical retropubic prostatectomy by one surgeon. At the time of operation, the prostatic urethra was anatomically dissected from the prostatectomy specimen and sent separately to pathology to evaluate for the presence of adenoma or prostate cancer.

RESULTS

All patients had clinically localized prostate cancer with routine preoperative evaluations, including negative bone scans for prostate-specific antigen (PSA) greater than 10 or Gleason score higher than 7. Pathologic specimens confirmed localized prostate cancer in 7 of 12 specimens. Positive margins were identified in 5, including 2 patients with locally advanced disease. All 12 urethral specimens showed residual prostate adenoma but no prostate cancer. Follow-up ranged from 8 to 16 months with a zero PSA for all evaluated.

CONCLUSIONS

Residual prostate adenoma is found on dissected urethral specimens during radical retropubic prostatectomy. Although urethral-sparing prostatectomy may improve continence after radical prostatectomy, residual adenoma may confound follow-up PSA results. Furthermore, the malignant potential of the benign periurethral adenoma is unknown. The patient and clinician must understand the implications of residual prostatic tissue when performing urethral-sparing radical retropubic prostatectomy.